Clinicopathological and immunohistochemical behavior of ductal carcinoma of the salivary and lacrimal gland in a Mexican Mestizo population.

PURPOSE: Salivary gland tumors are rare and include benign and malignant entities with different behavior and prognosis. Salivary gland carcinoma accounts for 0.2% of all cancers and 5-9% of head and neck carcinomas. We aim to describe the clinicopathological characteristics and discuss the immunohistochemical findings of salivary ductal carcinoma. METHODS: We obtained 17 cases (2.3%) of salivary ductal carcinoma (SDC) from 727 patients with parotid tumors at our cancer center from a database covering a 22-year period (1996-2018). Two pathologists confirmed the diagnosis and excluded 6 cases. Eleven cases were assessed by immunohistochemistry (IHC) for HER2, estrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), mammaglobin, P53, GATA3, S100, cytokeratins (7,8,14,18, and 20), P63, PAX8, calponin, and SOX10. RESULTS: Eleven SDC cases were in advanced stage, and 80% had metastasis. All cases were surgically treated, and 40% received different adjuvant chemotherapy regimens. we found that most patients were dead of disease. The histological and immunohistochemical analysis showed that 70% of cases were high-grade, 40% were positive for HER2, and 50% for AR. Moreover, a high Ki-67 proliferative index was detected in all cases. We observed luminal differentiation in 50% of cases. CONCLUSION: SDC is a rare entity and survival is very poor. It is histologically similar to ductal carcinoma of the breast. However, important differences exist that help to distinguish them in case of synchronous cancers. The clinical behavior of SDC seems to be more aggressive and IHC analysis is useful for designing therapies.

Lessons Learned from the Transoral Endoscopic Thyroidectomy with Vestibular Approach (TOETVA) for the Treatment of Thyroid Carcinoma.

BACKGROUND: Early detection of thyroid carcinoma has become commonplace. Consequently, the endoscopic approach has become a widely used method. OBJECTIVE: Our aim was to report our experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). METHODS: We reviewed the records of 46 patients who underwent TOETVA. Only patients with no regional lymph node metastases (N0) and fine needle aspiration biopsy-confirmed thyroid cancer were included. The surgical technique used was as described by Angkoon Anuwong. RESULTS: Forty-six patients with a mean age of 43.6 years (range 17-71) were included (37 women and 9 men). The mean time of surgery was 207 min (range 95-345), and the conversion to open thyroidectomy rate was 13% (six cases). CONCLUSION: TOETVA is an acceptable approach for thyroid carcinoma. Poorly differentiated cancer, as well as extrathyroidal extension, result in patients being unsuitable for TOETVA. It is imperative to identify the circumstances under which conversion to open thyroidectomy must take place.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Primary Frontoparietal Osteosarcoma.

Osteosarcoma in the craniofacial region is rare. A 43-year-old female, the patient, self-detected a 3-cm tumor of the right frontoparietal region 4 months before. An incisional biopsy was performed and a osteosarcoma was reported. At admission, a 4 × 5 cm tumor was present on the right frontoparietal region, without extending to the orbital region but the patient underwent surgery 2 months after admission. The delay was due to 2 episodes of upper respiratory tract infection that required resolution. At the time of surgery the tumor measured 8 × 9 cm. A craniotomy with resection of the dura mater and extension to the orbital roof, dural plasty with placement of fascia lata, as well as placement of a methylmethacrylate plate and anterolateral thigh flap was performed. No adjuvant treatment was done, The patient now has 2 months of postoperative oncologic follow-up.

Expression of hormonal receptors in osteosarcomas of the jaw bones: clinico-pathological analysis of 21 cases.

BACKGROUND: Sexual hormones have an important role in many hormone-dependent tumors like breast and prostate carcinomas, and also a relationship has been found with bone metabolism and bone tumors. Some studies have demonstrated that the expression of hormonal receptors (HR) in osteosarcomas (OS) of long bones is associated with gender, histological grade, histological type, and a possibly may be connection with pathogenesis and evolution. However, to our knowledge there are no studies of HR in osteosarcomas of craniofacial bones (OS-CF). OBJECTIVE: To assess the expression of hormonal receptors in OS-CF. MATERIAL AND METHODS: Twenty one cases of OS-CF were included in this study. Clinical outcome was obtained from clinical charts. Histological sections were reviewed, and immunohistochemistry studies for estrogen, progesterone and androgen receptors were performed. RESULTS: A striking female predominance was found (2:1), with a median age of 35 years. The predominant type of OS was osteoblastic (52.4%), and histological grade was high in 86%. Follow-up was obtained in 13 cases and ranged from 6 to 118 months (median 29 months). There were 8 patients (61.5%) dead or alive with progressive disease in the last follow up. Negative expression of HR was found in 19/21 cases; one showed weak nuclear expression for estrogen receptor, and another for androgen receptor. Progesterone receptor was negative in all cases. CONCLUSIONS: OS-CF mostly affected females, most of them were of the osteoblastic type and of high grade. Hormonal expression was practically negative in osteosarcoma of craniofacial bones.

Soft palate preservation after tumor resection with transoral laser microsurgery.

BACKGROUND: Management and preservation of the soft palate is dependent on clinical stage and tumor histology. However, available literature is scarce regarding the palate preservation with the use of laser CO2. OBJECTIVES: We report the results obtained after management with laser surgery and soft palate preservation in three patients with salivary gland neoplasms. METHOD: Three patients with minor salivary gland tumors were treated by means of transoral laser microsurgery. All tumors were assessed using magnetic resonance imaging. All tumors were >3 cm. Soft palate function was preserved and reconstruction was performed with primary closure. Patients began oral feeding the same day and were discharged after 24 h. CONCLUSIONS: Transoral laser microsurgery is recommended for treatment of soft palate tumors. This treatment can be considered a better option when compared with other modalities such as radio- or chemoradiotherapy which require a longer time of treatment, are more expensive and tend to produce significant toxicity.

Transcervical Approach in a Thrice Recurrent Parapharyngeal Space Tumor.

Parapharyngeal space tumors are rare and account for 0.5% of all head and neck tumors. Most of them are benign (95%), of which pleomorphic adenomas of the salivary gland are the most common. Due to their anatomical location, gaining surgical access while avoiding postoperative morbidity is the main limitation. We present the case of a 35-year-old male with a history of three transcervical resections of benign pleomorphic adenomas in the parapharyngeal space within the deep lobe of the parotid gland. The patient has been followed for more than ten years and maintains an adequate quality of life.

Conservative Treatment with CO2 Laser for oral Mucosal Melanoma: A case Report.

Mucosal melanoma of the head and neck is a rare and aggressive malignancy with poor prognosis even after extensive resection. A 76-year-old male with melanoma of the hard palate underwent CO2 laser resection as a conservative treatment to preserve his quality of life. Six months after lumpectomy the patient was asymptomatic and had no tumor activity. Recurrence is the rule. Local or regional relapse occurs at any time and patients eventually die from distant metastasis.

Carotid Artery Resection and Reconstruction due to Benign and Malignant Head and Neck Tumors.

OBJECTIVE: Carotid resection for head and neck cancer is rare, and serious complications may arise since such cancer is frequently detected in advanced stages. The objective is to describe nine cases of carotid artery resection and reconstruction due to tumor invasion. METHODS: The clinical records of nine patients who underwent carotid resection and reconstruction at our hospital were retrospectively reviewed. Carotid body tumors were evaluated with the aid of a vascular team in case carotid resection was necessary at the time of surgery. CT angiography to determine the status of the circle of Willis was performed in all patients who might undergo carotid resection and reconstruction in case of failure to restore cerebral blood flow and thus reduce possible sequelae due to ligation. RESULTS: Of nine patients, 6 had carotid body tumors, 1 had a thyroid tumor of conglomerate lymph nodes, 1 had a larynx tumor of conglomerate lymph nodes, and 1 had a myofibroblastic tumor. There were no intraoperative cerebrovascular accidents. One patient (11.1%) had a cerebrovascular accident secondary to carotid hematoma in the intermediate postoperative period that required vascular graft removal. One patient (11.1%) died seven days after surgery following an ischemic cerebrovascular accident. Eight patients remain asymptomatic, and 1 patient with recurrence and metastasis. CONCLUSIONS: Carotid resection remains a controversial issue in the treatment of advanced head and neck cancer. However, carotid resection and reconstruction are required for disease control, and complications such as thrombosis or vascular accidents may arise. Fortunately, this is a rare condition. We recommend carotid reconstruction for all patients in whom resection is required for tumor control. Ligation should be a last resort, as seen in the management of one of our patients.

Acrometastasis: The Tip of the Iceberg of Metastatic Disease from Thyroid Cancer. Two Cases Report.

Acrometastasis, especially in the hands and fingers, is a rare clinical condition resulting from primary cancers such as lung, breast, kidney, and, rarely, thyroid cancer. Acrometastasis tends to be the tip of the iceberg in patients with extensive systemic disease, which could be regional, pulmonary, skeletal, neurological, or all of them combined. Even though these tumors are clearly visible and symptomatic, the diagnosis is usually misleading because such distal metastatic disease is not thought of at first. In general, systemic treatments should be given to any patient presenting digital acrometastasis. We describe two cases of papillary thyroid carcinoma and digital acrometastasis as a sign of advanced disease.

Desmoid Tumor of the Posterior Neck: A Case Report.

Desmoid tumors are rare. They account for roughly 0.03% of all neoplasms and less than 3% of all soft tissue tumors. They are locally aggressive tumors with no known metastatic potential or dedifferentiation. A 29-year-old woman with no family history of neoplasms presented with a mass in the cervical region and moderate pain that had developed a year before. The patient underwent marginal resection of the bilateral posterior and lateral compartments of the neck. The histopathological report confirmed the diagnosis of desmoid tumor with nuclear positivity for beta-catenin. The patient received radiotherapy but did not show a favorable response; she has stable disease and takes colchicine at one-year follow-up.

Does compartmental resection really impact retroperitoneal soft tissue sarcomas? A retrospective analysis from a Single Referral Center.

BACKGROUND: The treatment of choice for retroperitoneal soft tissue sarcomas (RPS) is surgical resection; the outcomes with more radical surgeries, notably compartmental resection, remains a subject of debate. Arguments against it, include the complexity of the technique and high morbidity. MATERIALS AND METHODS: A retrospective analysis of cases treated in a single center from January 2010 to December 2019 is presented. Two time periods were evaluated: 2010-2015 and 2016-2019, corresponding to before and after the implementation of routine compartmentectomy. We evaluated the short- and long-term outcomes of compartmental resection compared to limited surgeries through a multivariate analysis of prognostic factors. RESULTS: A total of 176 cases were included, of which 102 met the inclusion criteria. The sex distribution was similar. The average age was 52.9 years, and the average tumor size was 24.5 cm. The most frequent histology was liposarcoma (65.7%), followed by leiomyosarcoma (12.7%), and malignant peripheral nerve sheath tumor (8.8%). The median follow-up period was 40 months. We found a lower local recurrence in the group treated in the recent period (compartmentectomy) 42.3% vs 20% p = 0.007. The median overall survival (OS) was 38.7 months, and there was no difference in distant recurrence between the two time periods. Postoperative morbidity was higher in the recent period (25% vs 10% p 0.041), with no difference in 30-day mortality. CONCLUSIONS: The implementation of extensive surgery, specifically compartmentectomy, for retroperitoneal sarcomas has been linked to reduced local recurrence. We recommend considering this surgical approach for RPS in alignment with current expert consensus guidelines, as highlighted by the updated TARPSWG consensus.

Upper lip malignant neoplasms. A study of 59 cases.

OBJECTIVES: To present the demographic data, clinico-pathologic features and therapeutic outcome of a series of upper lip malignancies. STUDY DESIGN: Retrospective study at a single Cancer Institution in Mexico City during a 14-year period. RESULTS: There were 59 cases, (30 males and 29 females); age range: 14 to 106 years (mean: 73 yr.). Antecedents of ultraviolet light and tobacco exposure were found in 20 (33.9%) and 16 cases (27%) respectively. There were 35 squamous cell carcinomas (59.3%), 19 basal cell carcinomas (32.2%) and one case each (1.7%) of adenocarcinoma NOS, adenoid cystic carcinoma, angiosarcoma, Merkel cell carcinoma and melanoma. There were 14 cases in stage I (23.7%), 14 in stage II (23.7%), 3 in stage III (5.1%) 14 in stage IV (23.7%) and 14 were not classified (23.7%). There were no significant differences with respect to the overall survival curve and the disease-free survival curve among surgical treatment and radiotherapy. In addition, there was not statistically significant difference in the overall survival and disease-free survival among squamous cell carcinoma and basal cell carcinoma cases with respect to the type of treatment. CONCLUSIONS: Upper lip malignant neoplasms are infrequent lesions. The present series describes the main clinico-pathological features in a hospital-based population in Mexico city and demonstrates some differences with respect to those found in the lower lip.

Supracricoid Partial Laryngectomy With and Without Neoadjuvant Chemotherapy in Glottic Cancer.

OBJECTIVES/HYPOTHESIS: To demonstrate that a group of patients who are not considered candidates for organ preservation can achieve organ preservation through neoadjuvant chemotherapy + surgery and to determine if there are differences regarding organ preservation, disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) after comparing such group with another one undergoing standard treatment. METHODS: Patients with laryngeal cancer were retrospectively analyzed and divided into two groups. Group A included patients who were initially treated with supracricoid laryngectomy. Group B included patients with T3N0 glottic squamous cell carcinoma with arytenoid fixation. Patients were offered neoadjuvant chemotherapy. Both groups underwent bilateral selective neck dissection of lymph nodes (II-V) and intentional search of the Delphian lymph nodes. RESULTS: Thirty-four patients were assigned to group A of surgery alone, and 16 patients were included in group B of induction chemotherapy. No statistical differences were found regarding sex, tumor localization, histological diagnosis, TNM staging, recurrence, or organ preservation. DFS, OS, and CSS at 60 months were the same in both groups. No statistical differences were found when comparing induction versus noninduction groups according to the T-stage in DFS, OS, and CSS. CONCLUSIONS: Neoadjuvant chemotherapy allows to perform conservative surgery in patients with poor functional prognosis or who are not good candidates for organ preservation at first. We could perform safe surgery, and there was no more recurrence. Hence DFS is not modified (i.e., there was no more recurrence); consequently, OS and CSS are not affected. Neoadjuvant chemotherapy plus supracricoid partial laryngectomy-cricohyoidoepiglottopexy is an oncologically safe procedure that preserves basic functions such as breathing, phonation, and swallowing. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:156-162, 2022.

Role of Neck Dissection in Organ-Preservation for Glottic Squamous Cell Carcinoma.

The surgical approach to the neck in laryngeal cancer depends on the tumor site and stage. Clinical practice guidelines recommend elective neck dissection in ≥ T2 N0 and all supraglottic cancers; however, there is no evidence supporting these recommendations. The objective is to evaluate the results of bilateral elective neck dissection in patients with glottic cancer who underwent supracricoid partial laryngectomy (SCPL) with cricohyoidoepiglottopexy (CHEP). Thirty-five patients diagnosed with ≥ T2 N0 laryngeal squamous cell carcinoma (LSCC) in a single-center retrospective study. Right-sided neck dissections yielded 900 lymph nodes, none of which were positive for metastatic disease. Left-sided neck dissections yielded 949 lymph nodes, one of which was positive for malignancy. Prelaryngeal (Delphian) neck dissection was performed in all patients. Out of 50 lymph nodes removed; one was positive for malignancy. Median overall survival was 172 months, and the 60-month overall survival was 87.3%. The 60-month disease-specific survival was 97.1%. Bilateral neck dissection and Delphian node dissection showed a low rate of metastasis (2.8%). Radical neck dissection may thus represent overtreatment; however, this surgical procedure could be justified to prevent regional recurrences.

Neutrophil-to-Lymphocyte ratio as a prognostic biomarker in extremities undifferentiated pleomorphic sarcoma.

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) in peripheral blood reflects the balance between systemic inflammation and immunity and has been reported as a prognostic biomarker in many neoplastic diseases, but its role in sarcomas has been poorly investigated. In this paper we analyzed the prognostic role of the neutrophil to lymphocyte ratio (NLR) in extremity undifferentiated pleomorphic sarcoma (eUPS). MATERIALS AND METHODS: We performed an observational, retrospective study including all eUPS cases treated at the National Institute of Cancer in Mexico City from January 2000 to December 2018. We used a ROC analysis to find the cut-off point where the NLR had the best value in predicting death (area under the curve: 0.73, P = 0.001). When the cut-off point was set at 3.09, the sensitivity of the test was 79% and the specificity was 59%. Demographic and clinical variables using log-rank test were also analyzed. Univariate Cox regression analyses and multivariate proportional hazards regression model were carried out to identify independent prognostic factors for Overall survival (OS), Disease-free survival (DFS), Metastasis free survival (MFS) and their association with the NLR. RESULTS: We included 112 cases, 53.6% were women. Most cases were stage IIIA (33.9%) or IIIB (30.4%) and Grade 3 (91.1%). High NLR correlated with metastatic disease at presentation (p = 0.001), locally advanced stage (p = 0.05), worse OS (HR = 1.33, 95% CI:1.01-1.75 p = 0.041) and higher risk of specific death (HR = 4.89, 95% CI: 1.88-12.72 p = 0.001). Non-use of chemotherapy (HR: 1.33, 95% CI:1.01-1.75 p = 0.041) was also associated with worse OS. CONCLUSION: The NLR is a simple yet useful prognostic factor in patients with eUPS when using a cut-off value of 3.09. Soft tissue sarcomas lack routine biomarkers that are applied widely, therefore we propose to consider and include the NLR in prospective trials or prognostic nomograms.

Bone invasion in soft tissue sarcomas of the extremities: An underappreciated prognostic factor. Bone invasion in soft tissue sarcomas.

BACKGROUND: Bone invasion is unfrequently reported in soft tissue sarcomas of the extremities (eSTS), it is difficult to assess preoperatively and its prognostic impact has not been extensively studied. The objective of this paper was to analyze the incidence and the clinical impact of histologically proven bone invasion in individuals with eSTS. METHODS: A retrospective analysis was performed using the medical files patients who had eSTS and were treated between 2012 and 2016. A 5 years survival was estimated using the Kaplan-Meier method and a Cox proportional risk assessment. The outcomes of patients with and without bone invasion were compared. RESULTS: 370 patients were included in the analysis. The median follow up was 25 months, the median age was 45 years (IQR 31-58). Bone invasion was found in 41 (11.08%). Median tumor size was 11.8 cm. The majority of individuals were diagnosed at stage IV (n = 116, 31.4%), followed by stage IIIB (n = 87, 23.5%). High histological grade was associated with worse OS (HR 2.23, CI 95% 1.36-3.65, p = 0.001). Absence of bone invasion was associated with better prognosis (HR 0.541, CI 95% 0.34-0.86, p = 0.009). OS was 27.3 vs 49.28 months. The disease-free survival (DFS) was 25.1 in bone invasion vs 45.23 without bone invasion. CONCLUSION: Bone invasion in individuals with eSTS is an independent adverse prognostic factor associated with lower OS and DFS; although infrequently reported, bone invasion might be considered as part of the staging in the future.

Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: A multicenter experience.

OBJECTIVE: Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC. METHODS: A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed. RESULTS: A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.

Oral mucosal melanoma: conservative treatment including laser surgery.

OBJECTIVE: To discuss the convenience of laser surgery as optimal treatment for melanoma of the oral mucosa. PATIENTS AND METHODS: A retrospective evaluation of four patients with primary oral melanomas treated at a single Cancer Institution in Mexico City. RESULTS: Two patients were treated with resection of the melanoma with CO2 laser together with extraction of the involved dental organs and curettage of the alveolar walls. These two cases had melanoma in situ with multiple isolated foci. The third patient had a lesion with vertical growth, who was submitted to partial maxillectomy along with selective dissection of bilateral neck levels I-V with a negative report and the fourth patient had a history of oral nodular melanoma and presented with lymph node metastasis. According to follow-up status, there was no distant metastasis in any of the patients reported here. CONCLUSION: In our experience, conservative management with CO2 laser is adequate for melanomas of the oral mucosa with extraction of the dental organs and curettage of the alveoli to achieve complete surgical resection microscopically without sacrifice of the quality of life. Management of the neck is controversial. We recommend selective therapeutic resection of the neck only if it is found to be clinically positive. Elective dissection has not shown to have an impact in overall survival.

Should metastatic lymph nodes be considered at the same clinical stage as distant metastasis in soft tissue sarcomas?

INTRODUCTION: Lymph node metastasis (LNM) in soft tissue sarcomas (STS) are uncommon, occurring in only 3% - 5% of all sarcomas, and are classified as Stage IV, along with distant metastasis (DM). This paper compares the prognosis of patients with lymphatic and DM, in extremity STS (eSTS). METHODS: A retrospective study was carried out in a high-volume sarcoma center; 853 patients with eSTS sarcomas were identified and classified from January 1, 1997 to December 31, 2017. Cases with pathological confirmation of LNM were included. Five-year survival rates were analyzed using the Kaplan-Meier method and the Cox proportional hazards model. RESULTS: LNM was present in 46 of the cases (5.4%), with an overall survival of 21 months (95% confidence interval [CI], 16.7 - 25.2), compared to 18 months (95% confidence interval [CI], 14.2 - 21.7) in those with only DM. Median recurrence-free survival was 21 months (95% confidence interval [CI], 19.7 - 22.4), vs. 20 months (95% confidence interval [CI], 16.2- 23.7), respectively. LNM only and DM only had also a similar OS of 21 months (95% CI 16.7-25.2) vs 18 months (95% CI 14.2-21.7. N1M1 cases had the worse median OS with 15 months (95% confidence interval [CI], 10.9-19.7) CONCLUSIONS: Overall survival and recurrence free survival in patients with lymph node disease and metastatic disease are similar. However prognosis is worse in N1M1. Use of systemic treatment in patients with LNM is not as common as in metastatic cases, this difference in treatment and the fact that prognosis is similar suggests that both biological behavior and effect of treatment have been underestimated. A subclassification of clinical stage IV might be the next step.